Assessment of Functional Limitations in Elderly

Person-Centered Care: Focus on Geriatrics

• The presentation focuses on person-centered care for geriatric patients.
• The date of the presentation is November 6, 2024.
• Presenter: Judith Jones, DDS, MPH, DScD
• Contact email: [email protected]
• Institution: Detroit Mercy Dental School

Objectives: Geriatrics 2

• Describe the principles of geriatric medicine.
• Detail functional declines in older adults.
• Outline the goals of long-term oral health care.
• Explain the Seattle Care pathways FDI Frailty guide.
• Discuss communication with other healthcare providers and caregivers.

Principles of Geriatric Medicine 1

• Age-related changes are a key consideration.
• Disease-related changes significantly impact the patient.
• Interactions between age and disease require careful evaluation.
• Disease chronicity is a common factor.
• Atypical presentations demand specific attention.
• Multiple pathologies (comorbidities) are often present.
• Polypharmacy raises concerns about drug interactions.
• Functional loss affects self-care abilities.

Functional Reserve = interaction of age and disease

• Saliva production and functional reserve decline with age.
• Normal saliva production (homeostasis) is impacted by age and disease.

E.g.: Drop in Plaque pH after 10% Glucose Rinse

• Graph displays the decline in plaque pH following a glucose rinse over time, differentiating various caries activity levels.

Saliva Production in Healthy Adults

• Healthy adults produce up to 1.5 liters of saliva daily.
• Paired parotid, sublingual, and submandibular glands are the main source.

Normal and Low Salivary Flow

• Table shows normal and low unstimulated and stimulated salivary flow rates (ml/min) for whole saliva and parotid.

Principles of Geriatric Medicine 1 (continued)

• Age-related changes are crucial factors in geriatric medicine.
• Disease-related factors heavily impact patients.
• Interactions between age and disease pose specific challenges.
• Chronic conditions (e.g., Type 2 diabetes, heart disease, stroke, depression) are common among the elderly.
• Atypical disease presentation presents diagnostic challenges in older adults, such as acute myocardial infarction.
• Multiple pathologies (comorbidities) are prevalent.
• Polypharmacy, involving multiple medications, significantly influences patients.
• Functional limitations decrease the ability to meet one's own needs.

Frailty (Pretty et al. 2014)

• Frailty is characterized by increased vulnerability to stressors.
• Age-related decline in physiological reserve across neuromuscular, metabolic, and immune systems is a hallmark.
• Homeostenosis is a key concept related to frailty.

Functional Presentations of Illness

• Common presentations of illness in elderly patients include stopping eating/drinking, falling, urinary incontinence, dizziness, acute confusion, new/worsening dementia, weight loss, failure to thrive, and fatigue.

Percent of Adults with Limitations Due to Chronic Conditions, USA, 2016

• Percentage of adults with one or more limitations due to chronic conditions increases with age.

Percent with Disability Increases with Increasing Age, 2014 (CDC NHIS)

• Percentage of individuals with various disabilities, including self-care, cognition, communication, mobility, hearing, and vision, increases drastically with age.

Sensory Impairments Increase with Increasing Age, USA, 1999–2006 (NHANES)

• Various sensory impairments, including visual, hearing, balance, and loss of feeling in feet, show a correlation with advancing age.

ADLs: Basic and Instrumental

• Functional limitations for basic and instrumental activities of daily living (ADLs) for different age groups were shown in a graph.

Difficulty with IADLs, 65+ Year-Olds, USA or Difficulty with ADLs, 65+ Year-Olds, USA

• Percentages of 65+ year-olds experiencing difficulties with instrumental activities of daily living (IADLs) or activities of daily living (ADLs), categorized by institutionalization vs. community dwelling.

Comorbidity: Common Coexisting Conditions in the Institutionalized Elderly 1

• Common co-occurring conditions in institution-dwelling elderly patients include heart failure, depression, dementia, chronic renal failure, angina, osteoarthritis, osteoporosis, gait disorders, urinary incontinence, vascular insufficiency, constipation, diabetes, anemia, sleep disturbances, adverse drug reactions, and sensory deficits.

Evaluation of the Frail Elder

• Essential steps for evaluating elderly patients include patient identification, chief complaint, history of present illness, dental history, past medical history, review of systems, medications, allergies, diet history, social history, habits, and physical examination.

Current Medications (John Kelly)

• Crucial factors in evaluating the elderly include disease severity, eliciting additional medical issues, assessing health literacy, and reviewing prescribed/over-the-counter medications.
• The brown bag approach can be useful to gain a complete picture.

Medication History Assessment

• Medication history is a critical aspect of patient work-up.
• Evaluating this aspect can be complex and time-consuming.
• Key aspects to consider in medication histories include adverse drug reactions, interactions, xerostomia, sialorrhea, orthostatic hypotension, psychiatric disturbances, movement disorders, gastrointestinal upset, and soft tissue reactions, stress tolerance, altered host resistance, allergies, and antiresorptive agent-induced osteonecrosis of the jaw (ARONJ).

Medications and Bleeding: 6 letter “A” drugs

• This slide lists common medication types categorized by their relationship with bleeding, specifically drugs containing six letters and starting with 'A'.

Medications and Bleeding

• A Fib is a condition that can cause bleeding and affects about ~10% of 80-year-olds and increases to 18% of 85-year-olds.
• Anticoagulants are used to prevent strokes and include Warfarin (Coumadin®), newer anticoagulants (e.g., Pradaxa®, Xarelto®, Eliquis®), and INR monitoring (therapeutic range 2-3.5).

Prevalence of Reported Xerostomia

• Graph illustrating a strong correlation between increased xerostomia and increasing numbers of medications taken by patients aged 20-80.

Signs of Oral Dryness

• Image of oral dryness, potentially from a medication, used to illustrate oral dryness symptoms.

Questions to Identify Salivary Problems 1

• Questions for identifying salivary problems include difficulty swallowing food, need for fluids to swallow dry food, mouth dryness while eating, feeling like saliva is too scarce.

Oral Exam Emphases

• Oral examination focuses on evaluating function (mastication, speech, swallowing, alveolar ridge resorption, prosthetics), symptoms (pain/discomfort, dry mouth, taste, and smell), pathology (caries, periodontal disease, candidiasis, stomatitis, cancer), and esthetics (color, form, natural appearance).

Clinical Decision Making and Rational Care

• Key factors influencing clinical decision-making and rational care include patient desires, dental need severity, impact on quality of life, positive outcome likelihood, treatment alternatives, treatment tolerance, oral health maintenance, financial resources, and dentist capabilities.

Patient/Medical POA Communication (Berkey)

• Strategies for patient/medical power of attorney communication focus on clearly outlining benefits, risks, and costs of treatments, outlining a staging care plan, promoting questions and reasonable treatment option discussions, respecting patient autonomy in treatment modifications, and obtaining informed consent, using understandable language.

Dental Care Priorities

• Prioritized dental care involves resolving pain and infection, performing extractions of high-risk teeth, managing periodontal issues, controlling caries, and managing temporary restorations for prosthesis repair/removal.

Dental Care Strategies (Berkey)

• Strategies for dental care emphasize shorter appointment lengths, a positive and comfortable office environment, and capable practitioners. A flexibility to evolve treatment plans as patient's needs change throughout the course of care.

Surgical Approach

• Advantages of surgical approaches include caries removal, alteration in oral flora, esthetics, and operator control.
• Disadvantages include anatomical considerations, lifespan of materials, complications when restoring around the corners, and potential for microleakage.

Chemical Approach

• Advantages of chemical approaches include preserving tooth structure and minimizing surgical risk for patients.
• Disadvantages include discoloration, chronic infection, microbiological milieu disturbances, potential pulpal necrosis, and challenges in long-term maintenance.

Contamination

• Different restorative materials have varying levels of sensitivity to contamination with amalgam being the least sensitive and composite the most sensitive, with glass ionomer falling in between.

Continuum: Glass ionomer Composite

• Table showcasing the comparative analysis of physical properties, bond strength (MPa), fluoride liberation, and fluoride recharge among resin-modified glass ionomer, compomers, and composites.

Atraumatic Restorative Therapy (ART)

• Atraumatic Restorative Therapy (ART) is a treatment method emphasizing the removal of carious tissues using hand instruments followed by restoration of the prepared tooth with adhesive restorative material.

Essentials for Clinic

• Key aspects of dental clinic management include understanding the patient, valuing every experience as a learning opportunity, considering the end goal from the beginning, presence within the context of each patient's situation, listening attentively, ensuring preparedness, maintaining organization, and documenting information.

!KNOW! Seattle Care Pathway Approaches

• The key approaches include assessment, prevention, communication, and treatment of patients, aiming for appropriate care with a wide margin of benefit over risks for patients.

The Seattle Care Pathway

• A structured, evidence-based approach for older adult dental care, developed in Seattle in 2013.
• Critical to address varied and adequately educated workforce needs.
• Important considerations include demographic shifts, addressing frailty, careful assessment of level-of-dependency, and appropriate prevention and communication strategies.

Seattle Care Pathways: Definitions

• Definitions of different dependency levels (no/low, pre-, medium, high) based on oral health, fitness level, and treatment needs.

Seattle Care Pathways: Assessment

• Different assessment strategies tailored to no/low, pre, medium, and high dependency levels.

Seattle Care Pathways: Prevention/Communication

• Prevention and communication strategies specific to different dependency levels (no/low, pre, medium, and high).

Seattle Care Pathways: Treatment

• Strategies for treatment planning adjusted to the varying dependence levels (no/low, pre, medium, and high).

Most Important Outcomes (Jones and Brown, 2000)

• 5 main priorities of oral care for older adult patients: free from pain, prevent aspiration risk, necessary emergency care when needed, prevent mouth infections, and establish frequent and consistent daily mouth care.

Top Ten Outcomes (Cont'd) (Jones and Brown, 2000)

• Additional priorities for oral care include comfort of loose teeth and gums, proper tooth brushing, support staff for oral care maintenance, timely identification of oral care problems, and early oral care problem detection.

Ethical Issues

• Ethical considerations in patient care pertain to patient autonomy, decision-making processes in patients incapable of making their own decisions, documenting patient choices, collaboration among patients, families, and health providers.

Avoid Futile Care

• To avoid futile care, understand when there's no hope of cure or benefit from a treatment, adopt the hospice approach, involve both the patient and family in treatment and care, maintain previous treatment and care practices, and adopt a palliative approach to treatment decisions (frequent check-in).

Patient (Case Study)

• A 69-year-old Caucasian male with presenting complaints of a standard check-up, but with a history of 4 years of no dental care due to the burdens of prior disease (PDAT).
• Several teeth are missing, requiring attention.
• Significant dental issues, including fractured restorations and generalized cervical decalcification and caries, exist.

An Evidence-Based Approach

• An approach to resolving a clinical problem includes presenting the clinical problem concisely, performing targeted reviews of the literature, focusing on the problem at hand, using available evidence, and improving patient care through implementation of new and valid information.

1.23%APF q3-6 mos * 18 mos

• Image illustrating an example of a patient's oral health condition, consistent with the use of 1.23% APF every 3-6 months for 18 months.

Fluoride remineralizes!

• Graphical representation of a patient mouth condition, demonstrating the effectiveness of fluoride in remineralizing teeth.

Caries incidence in patients with AD or Caries incidence graph

• Data shows the occurrence of caries in patients diagnosed with Alzheimer's disease and in patients for comparison without age-related diseases.

Remember how fluorides work?

• Fluoride's impact on oral health comprises reducing enamel solubility impacting plaque composition and colonization, interfering with plaque metabolism, and most importantly enhancing remineralization.

Fluorides: % versus ppm

• Table showing the percentage and parts per million (ppm) concentration of various fluoride treatments.

Delphi Survey

• Using structured group communication across rounds to assess a complex problem with expert consensus.

Surgical Approach

Chemical Approach

Contamination

This quiz explores various aspects of functional limitations and dependency assessments in elderly populations, particularly those aged 65 and above. It covers prevalence rates of disabilities, assessment processes, and strategic health plans. Test your knowledge on these critical topics affecting senior health care.