Seniors’ oral health: planning for the future Author: Jackie Smorang, BA, Dip DH, MSEd Presented by Dr. Luke Shwart Manager, Community Oral Health Services www.calgaryhealthregion.ca/hecomm/oral/oral.htm APHA Conference • 2003 Nov 17 I’m a U Manitoba grad 1976, and have worked in dental public since 1980. For the last 6 years I’ve managed the Community Oral Health program for Calgary Health Region. This report was researched and written by Jackie Smorang - also a U Manitoba grad. I won’t say her graduation date because it was even before mine. Some of you may have had this experience when interviewing recruits for jobs - some of the applicants weren’t even born when I started practicing. It makes me wonder - “How come they’re letting all these kids into professional schools these days?” That little reflection is a good segue into this topic: Seniors’ Oral Health. By the time the new graduate I hired has worked as long as I have, I will be well into my senior years, and these issues will affect me directly.

Overview A. What is oral health B. Seniors demographics C. Best practices review D. Status quo in Calgary E. Recommendations/Action Plan The 160 page report consists of 5 sections: A. defining the issue B. numbers and projections C. what’s the state of the art? D. what’s happening right now E. Where should we go, what do we have to do to get there?

Persons age 65+ y Calgary Health Region In the Calgary Health Region the number of people over 65 years will double within the next 20 years. Although the numbers alone suggest an issue is arising, the picture is a little more complicated. It’s easy to depict seniors as a large blue rectangle, but they are not a single uniform group.

Seniors: a continuum independent ------ need help ------ dependent As we age, we move from independence to needing help. Independent seniors access dental care as would any younger adult. At the other end of the continuum, dependent seniors require help for even the basic requirements of health. Health status is dynamic: people may be independent, and move along the continuum when suffering from some ailment, but then move back again after recovering. In a supportive environment, a minor loss can be compensated for, but in an non-supportive environment, a minor functional loss may lead to a loss of independence. How can we be sure that care facilities are supportive environments when it comes to oral health?

Independent-living adults: % edentulous (1991 Ontario) Edentulous people have lower intakes of protein, calcium, iron and Vit C (35). Some of these folks are malnourished! Over the last few decades the proportion of older adults who have lost their teeth is declining. This graph simplifies the issue: the highest rates of edentulism are not in independent-living seniors, but in long term care facilities where it ranges from half to three-quarters of the residents. 35: Locker D, Matear D, Lawrence H. General health status and changes in chewing ability in older Canadians over seven years. Journal of Public Health Dentistry 2002;62(2):70-77. In four Ontario communities.

Edentulism: age or cohort? Older adults: inferior access to care over lifetime less sophisticated dental treatment determinants of health disadvantaged low income uninsured less educated We tend to think that teeth are lost with age, but the literature shows other factors are equally or more important. The 1970’s wave of dental insurance helped generate a cohort of adults with better oral health. Tooth loss is in fact more related to cohort - the determinants of health, than it is to age. This means we are entering uncharted waters. We will soon have a large population of elderly people with reasonably-intact natural dentitions. And this is the crux of the issue we will face: Seniors greatly benefit from keeping their natural teeth BUT there is a burden associated with maintaining those teeth.

Service usage by nursing home residents (2000 US) Although we advise seniors to have annual dental examinations, the usage in nursing homes may be appallingly low. This North Carolina study found that use of dental services trailed all other health services.(38) In Canada the elderly visit the dentist less than any other age group. Calgary surveys find that just about half of the home-living seniors go to the dentist, yet more than 60% of them have most or all of their natural teeth. One of the main reasons they don’t go is lack of perceived need. A majority of elderly believe that they do not need to see the dentist unless: it hurts they cannot eat, or they’re embarrassed by their teeth. A large cohort of the elderly accepts oral discomfort as an inevitable consequence of aging. (38) Markenson AJ Long-term care survey and certification guide. Eli Research Inc. Chapel Hill North Carolina 2000: 1401-1432 *Canadian Task Force on Periodic Health Examination

Seniors’ self assessment vs. professional assessment (1995 Winnipeg) Lack of perceived need shows up repeatedly in the literature. In this study of community-living seniors, almost all thought their oral health was good or average, but professional assessment found that almost all of them needed care: 100% of those with teeth, and 89% of those without natural teeth. Galan D, Brecx M, Heath R. Oral health status of a population of community-dwelling older Canadians. Gerontology 1995;12(1):41-48.

Barriers to Dental Care lack of perceived need financial constraints transportation and access difficulties poor health When asked why they don’t access dental care, seniors suggest 4 reasons: 1. Oral health is not important, so no need for care is perceived 2. Dental care is expensive. However, studies also show that availability of free or reduced-cost dental services increases utilization by seniors only slightly. (45) 3. Access is a barrier. Home-bound seniors require help and wheelchair-accessible offices. Residents of care centres are limited in their ability to leave the site. 4. Poor general health is a barrier cited more often by caregivers than by seniors. 45 Kiyak HA. An explanatory model of older persons’ use of dental services. Implications for health policy. Medical Care 1987 25(10) 936-952

Best practices Literature review Working examples Evaluation Educational institutions Part three of the report is about best practices. This section makes up almost half of the report, and as unfair as it is to summarize 70 pages in a few minutes, I’m going to do exactly that.

Problem: lack of evaluation Measurement of changes in oral health status of elderly is complex No universally accepted index More research needed Best practice, by definition, means that the intervention has been evaluated. However, the literature points to a serious lack of evaluation. One reason is that measurement of changes in oral health status of elderly is complex. Another reason is that there are at least three or four competing indices. [“Clinical Oral Disorder in Elders” CODE - UBC index/model under development and in 2 y pilot project to in Vancouver & Richmond Health region]

Integrated Oral Health Care Model 1999 B.C. Karen Moore Resident & Family Community professionals Care staff There are many different programs out there, but one conceptual model with a good working example is in B.C. Karen Moore - geriatric nurse clinician researched & developed the model. It uses the dental hygienist as a coordinator who: - conducts oral assessments consults the resident and family develops individual oral hygiene care plan and recommends oral hygiene products provides staff education provides or coordinates denture labeling and cleaning provides treatment within scope of practice and coordinates follow-up In this model the hygienist is a key part of an interdisciplinary care team, liaising with physician, dentist (or denturist) and others as needed. (76) Moore, K. Establishing comprehensive dental hygiene care. Probe 1999;33(5):145-148. Dental hygienist as coordinator

Recommendations Summary Education and information (oral health linkage to general health) needed for seniors, health professionals, caregivers and policy-makers. Include oral health in Seniors’ Programs assessments. Oral care standards for residents in regional care facilities. Targeted dental treatment program for at-risk low-income seniors. This slide summarizes the recommendations from all the stakeholders: residents, families, caregivers, professionals, key contacts: 1. People need to know more about this issue and why it is important 2. Oral health needs to be part of the seniors’ assessment. It has implications for mental, physical and emotional health, so why isn’t it included? 3. Care facilities need written standards about what is expected for residents’ oral health. 4. Some seniors cannot afford needed dental care, something needs to be done for them.

Action Plan — 5 parts 1. Initiate accord across all Regional programs 2. Use health promotion strategies to generate awareness and action 3. Identify gaps and priorities 4. Generate innovative strategies 5. Advocate for change The report concludes with an action plan to move forward and make a difference in seniors’ health. This report does not provide all the answers, but it highlights how to start addressing the problems. 1. We need agreement among managers and policy makers that the issue is important 2. Use the Health Promotion Framework as a basis for generating interest and action 3. Clarify the gaps and priorities in the region 4. Be innovative: create, adapt, develop new approaches 5. Lobby legislators and others who can make a difference

1. Initiate accord across all Regional programs a. Oral care is an essential element of primary care and integral to the general health and well-being of older adults b. Include oral health in seniors’ general health assessments c. Collect oral health information. Action step 1: We need broad agreement at the top levels of the organization that the issue is important. Only after we have that in place can we really move forward. Right now the Home Care health assessment of seniors asks a single oral health question: “Do you have dentures?” Seniors deserve information that assesses their own ability to speak, eat and socialize, and that helps them maintain their oral and general health.

2. Use health promotion strategies to generate awareness and action a. Raise awareness among seniors, professionals, policy-makers, health care personnel, the public b. Improve knowledge among Regional health care providers c. Develop partnerships in the seniors’ community to generate and leverage oral health promotion Action step 2: Too often, oral health is not addressed because it is not valued. We need to build community awareness of how oral health affects a senior’s general health and life. In promoting information and awareness we should see partnerships develop among stakeholders. Then seniors groups, agencies and other organizations may take the issue forward.

3. Identify gaps and priorities a. Review current Regional programs b. Review knowledge, attitudes and practices by care facility staff c. Develop standards/outcomes for care facilities d. Develop a continuing education plan for Regional dental staff re: oral care needs of the elderly e. Identify seniors’ oral health needs and priorities seniors’ focus groups dental health professionals f. Report (for future program planning) Action step 3: a detailed look in our own backyard. A. What are the current duplications and gaps? B. Ask care facility staff about the work they do C. Come to an agreement on standards and outcomes in care facilities D. Inform our own Community Oral Health staff E. Convene focus groups to identify seniors’ oral health needs & priorities F. Write it up - so there is a document to assist future program planning

4. Generate innovative strategies a. Develop innovative pilot project(s) b. Improve communication and cooperation between individuals and agencies (re: seniors’ oral health) c. Evaluate projects and initiatives impact on seniors’ oral health assist in resource allocation d. Share information about ways to improve seniors’ oral health care Action Step four: be innovative A. Find new ways to address seniors’ needs and priorities. Convene a task force to develop ideas. It would include community groups, health societies, business and social service groups, and the dental community. B Devise a method for better communication and cooperation C. Evaluate our initiatives. To make better decisions about spending resources, we need to know what impact we’ve had. D. Share our learning and experience.

5. Advocate for change a. Advocate for provincial standards for care facilities b. Advocate revised provincial regulations for Dental Hygienists c. Advocate that all students in health professions learn oral health needs of seniors And the final action step: Advocate for change There are important factors that are outside our control, but within reach of our influence Legislators need to know that care facility standards for oral health should be addressed on a province-wide basis. They also need to know that changing of regulations for dental hygienists has worked in other areas. Educational institutions for health care workers need to include seniors’ oral health on the curriculum.

Vision General awareness of importance and implications of seniors’ oral health Oral health services to seniors in various living situations Oral care programs sensitive to concerns of the elderly and reflect the diversity of their financial, physical and mental conditions No financial and physical barriers to care Imagine a new world where - everyone knows that oral health is as important, or even more important, for seniors as it is for everyone else - where dependent seniors do not have to worry about accessing oral health care - where programs are in place to serve the needs of a diversity of individuals - where there are no financial or physical barriers to receiving care

Creating the Future No single, simple, strategy It requires effort, perseverance, resources and changes in attitude Creating that future isn’t like pulling a rabbit out of a hat. It’s a process that will take community building, lobbying, promoting. It will require effort and resources, and changes in attitude. But it’s a process that we must begin.