Older people - Francis report, ageing dentition and capacity conundrums Flashcards
The francis report
- Revealed appalling care of older people
- Shocking reports of abuse and neglect
- Not a single episode
- Accepted behaviour
- Resistance to change
Oral health of the elderly
- The good
- The bad
- The ugly
demographics of age
Scotland (2013)
- Total population ~ 5.3 million
- 17%: < 16
- 65%: 16-64
- 18%: 65+
An ageing population
- By 2037 those aged 65 and older will make up 25% of our population, an increase of 59%
A population living longer
- The average age of death rose from 71 in 1982 to 75 in 2011
- Older age groups increasing while younger age groups are static/decreasing
challenges in the ageinig dentition (5)
- Increased number of people with long term conditions
- 66% of over 65s will have a chronic condition by 2035
- Increasing age with concurrent increase in co-morbidities
- Polypharmacy
- Over 65s currently taking 10 medications or more = 16.4%
- Xerostomia – common side effect of drugs and also effect of taking many drugs – so effect compounded and dry mouth become profound
- Over 65s currently taking 10 medications or more = 16.4%
- dementia
- Set to rise from 71,000 to 127,000 within the next 20 years in Scotland
- Only 46% of people with dementia in the UK currently have a diagnosis
- Communication with patients
- Capacity/consent
- Set to rise from 71,000 to 127,000 within the next 20 years in Scotland
- More people are keeping teeth for longer
- Proportion of Scots retaining some teeth in 2012
Over 75s 54%
65-74 73%
55-64 86%
issue of people keeping teeth longer
Initially looks good – more people retaining their teeth for longer
- But research shows that 90% of elderly and in care have untreated dental decay – both coronal and root caries
how has oral health changed in care homes over the decades
Many studies – every decade for 40 years
Yet no changes
Need to raise the importance of oral health for all categories of patients but especially for dependent patients
Francis Report - why do we tolerate low levels
“Too Great a Degree of Tolerance of Poor Standards ”
Why do we continue to tolerate this?
Became expected norm
Likely enter care home/ward with poor OH – but once admitted should be dealt with – but it hasn’t been
neglect here
Stroke pt
- Ulceration – can easily see cause*
- Completely dependent on carers to call in dental team*
- Extract or bevel edges to prevent further ulceration*
neglect here
- Multiple stroke pt with chronic anaemia*
- Continued to be given iron tablet – but couldn’t swallow tablets*
- Lay at back of mouth and burned a hole through side of tongue, cheek and floor of mouth*
- Inexcusable – no one checked*
- Liquid iron would’ve been more tolerable*
issue here
- Supported at home not in hospital*
- Unpleasant bacterial infection that is widespread extra-orally not dealt with*
- Grossly carious and blacked teeth*
main dental issue as a result of stroke
lose abilty to look after own oral hygiene
become dependent
4 oral diseases seen commonly in elderly
- Caries/root caries
- Periodontal disease
- Oral mucosal disorders
- Oral cancer
oral cancer prevalence
- One fifth of oral cancer cases diagnosed in the UK occur in people aged 75 and over
- Often present late, at an advanced stage
- need to be checked even if edentulous
- Regular dental examination important
- Help with oral hygiene provides opportunity for carers to observe changes from normal and arrange a dental appointment
- anything Abnormal - get it checked
what is avoidable harm
- Francis report*
- “…and they must be protected from avoidable harm”*
Aspiration pneumonia may be fatal
- Oral bacteria are the main source of infection for aspiration pneumonia
- importance of cleaning mouth more than aesthetics - bacteria harbour
- Poor oral health results in an increased bacterial load and subsequently increased risk of aspiration pneumonia
- Millions of MO even when clean
- Makeup of bugs change as well - danger
- Millions of MO even when clean
- Improved oral health reduced aspiration pneumonia
issue here
- Staphylococcus mucositis (Glasgow 1990s)*
- Complete lack of oral care
- Mouth breathing stroke pt*
- Nil by mouth
- No one cleaning mouth so detritus (dead mucosal cells, saliva secretions) thick/gloopy – can choke due to mucosal plaque tethering tongue to palate*
is our dental care of elderly safe?
- Berwick Report*
- “Patient safety should be the everpresent concern of every person working in or affecting NHS-funded care.”*
no
why is it tolerated?
commonly
- Francis Report*
- “ … and they must be protected from avoidable harm and any deprivation of their basic rights ”*
4 points from UN convention of human rights
- Article 5
- No one shall be subjected to degrading treatment
- Article 21
- Everyone has the right of equal access to public service in his country.
- Article 25
- Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care
- Article 27
- Everyone has the right freely to participate in the cultural life of the community
example of degrading treatment in francies report
“A lady of 95 years who was registered as blind and diabetic and suffering from pneumonia was left to sit in a corridor in A & E at Stafford Hospital for three hours. The care, when it was eventually provided, was good.
- Nobody talking to her, nobody looking after her
- Care when eventually given was good – just too busy
The next day the patient was transferred to Ward 10 where she was left in soiled bed clothes** and no one answered when she rang her call bell for help. **When the patient’s false teeth were lost she was assured that the dental department would provide a new set**, yet weeks later she was told such a service was not available. **The food provided to the patient was not suitable for a lady with no teeth** and despite being blind, **staff offered her no assistance with feeding**. For the patient’s entire stay, which was several weeks, **she was not washed or cleaned.
- Lied to
- Neglected for several weeks
examples of failure of care in Glasgow
Mrs McGaw became very unwell whilst in a care home – care home weren’t aware she even had denture
- Transferred to a hospital maxillofacial unit by GMP - oral cause suspected
- Died of ischaemic heart disease but her oral condition raised serious concerns
- Denture might have been left in her mouth for a period in excess of two weeks (thought to be 2 years)
Care home did not meet the oral health needs of those who needed help
Serious failings were identified and have since been addressed
- A body of opinions from the medical witnesses believe it quite likely that the denture contributed to Mrs McGaw’s death
- stroke pts unable to remove denture themselves – loss control of limb – but also cannot speak to communicate denture – mouth needs to be checked*
difficulties of access to dental care for elderly (4)
- Mobility and access to dental premises
- Disability and discrimination act
- Communication
- Dental anxiety
- Cost
issue with hospital transport and dental care
- However, pts needing hospital transport can only be taken to hospital sites not high street dentists*
- Tried to get this changed for years
- Booked by pt – need good communication*
- May not be able to bring family member/carer as not enough space in ambulance*
importance of oral health for general health
- Pain free and comfortable
- Risk of life-threatening spread of oral infection
- Infection can smell and taste unpleasant, inhibiting social interaction and thus self-wellbeing
- Nutrition
older peoples prespective of oral health in QoL
- Older people perceive oral health as important to their own quality of life
- Eating
- Comfort
- Appearance
- Smiling/laughing/kissing
- Personality
- Easy fix for quality of life – cleaning mouth*
- But no action to do this
issue that occur to eating and oral health issues
Loss of teeth leads to:
- Impaired masticatory function
- Avoidance of foods that are hard to chew
- Not meeting nutritional needs
- Increased intake of processed, high cholesterol and lipid based foodstuffs
Too dry or sore
- Food intake restricted = restricted nutrition
- General health compromise, oral health – teeth and supporting structures
Eating should be enjoyable – often one of the few pleasures left
how is oral health important so indviduals can take part in social interactions
- Family visits
- Talking to friends
- Participating in social events
- Eating together
- Physical closeness is really important for emotional wellbeing*
- Unable if oral hygiene so poor and repugnant*
issues of caring for elderly in practice
- Caring for the elderly is not business friendly
- Domiciliary dentistry
- Arranging transport to dental clinic
- Longer appointments
- Failed appointments
- Is our current workforce big enough to meet the need?
- Patient centred care
- Care of this group cannot be allowed to be compromised by financial constraints
key way to target issues highlighted in Francis report
education and training for nurses and carers
‘Caring for smiles’
- A guide for oral health professionals to deliver training for staff in care homes
- Enables carers to provide a high standard of oral care for dependent older people
NES not have qualifications for Oral health for carers
barriers to making postitive changes in elderly OHRQoL
- Oral health is a low priority in care plans – need to be equal
- Carers have limited knowledge of oral health
- Carers have difficulty in gaining access to residents’ teeth
- High turnover of care staff
- Poorly paid care staff
- Do they feel valued?
Berwick’s key principles
- Place the quality of patient care, especially patient safety, above all other aims
- Engage, empower, and hear patients and carers at all times
- Foster whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work
- Embrace transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge
research into elderly oral health care
- Community Oral Health Research Group
- Oral Health of Older People research theme
- Scottish Oral Health Research Collaboration
the life course of a dentition
Start edentulous and progress through
- Rarer to become edentulous at end now
Restorations in between – varying degree
things used to imporve oral health care for younger population
Laws, intervention, public health upstream approaches happening so that children and young people will have better outcomes
loss of teeth through life reasons
Better now at controlling risk factors and reducing tooth loss
Always going to be socioeconomic issues – but improving public health ability to prevent alcohol/smoking induced issues, improving oral hygiene, educating on diet etc
issue of more people having teeth for longer and living longer
% of edentulous adults declined consistently over the last 30 years
But dental decay prevalent in the older dentate population
- Higher risk of Tx – physically frail, mentally confused, maybe house bound or instutionalised
are we prepared
By 2040 those of 64 will make up to 25% of population
cost of dementia
economy Vs research investment
- Every dementia patient costs the economy ￡27,647 billion per year: more than the UK median salary (￡24,700 billion).
- patients with cancer cost ￡5,999, heart disease ￡3,455, stroke ￡4,770 per year.
why is there a large unmet need for oral care in care homes
research – hard to obtain
lack of funding for research and care care home residents often excluded from research – dementia, capacity etc
- need to ID barriers to over them
death of a dentition
5 causes
- Oral hygiene
- Caries
- Periodontal disease
- Oral mucosal disease
- lichen planus
lichen planus
- Comfort when eating
- Difficulty in performing oral hygiene
- may not be able to communicate this well
- Risk of malignant transformation
- Management of disease cannot just stop because they have dementia
- Systemic disease and polypharmacy may contraindicate certain therapies
Can the Oral Medicine Consultant perform domiciliary care? Busy
Often Dx younger but as become dependent on care – fall off radar and not follower up
head and neck cancer
Early Assessment, Diagnosis and Management are essential
- Present with more advanced disease at
- assessment
- Delay in diagnosis
- Symptoms unable to be communicated
- Lack of attention paid
- Misdiagnosis
- Those who have undergone previous oncological care – inc recurrence risk, more speicifc health needs (poor mouth opening, salivary function etc)
- Surgery
- Radiotherapy
3 things to always do for a good examination - soft tissue
- Regularly
- Good light source
- Dentures out the mouth – can see mass on lower left that would be a high risk site – easily missed on local in with dentures in
aspiration pneumonia
life threatening spread of infection due to unclean mouth
- Most common cause of death in patients with dysphagia associated with neurological impairment
- Crusting around oral mucosa contains staph aureus – introducing bacteria
- Incidence: 18% nursing home acquired vs 5% of community acquired
- Preventable – good OH on regular basis
often seen in
-
Older adults who are dependent
- Receive food via NG tube or
- Mouth breathing
- Nil of mouth
- Oral health neglected – not cleaned
ART caries management
Atraumatic Restorative Technique
- good for elderly
- No fee in Scottish Dental Remuneration (like regular oral hygiene visits – gold standard prevention)
Stepwise approach
-
Excavate caries as far as possible without breaching the pulp – removing infected soft dentine but leave affected dentine as layer on top of pulp. Seal in with GI
- Cut off food supply for bacteria and caries- Stabilise things
- More cleansable
- Only spoon excavator and GI – so little equipment if domiciliary visit
fine line balancing between
treat to what extent
64 Year old Male
Referred via multiple sites – finally 4th referral to Special Care at RAH
Medical History:
CVA 2003
Vascular dementia 2013
High blood pressureDiabetes
Walks with a stick and arm support required.
Medications:
Amlodipine; aspirin; metformin; metoprolol; paroxetine; ramipril; ranitidine; simvastatin; temazepam
Social History
Wife is main carer and POA – she reports various access difficulties to services over last 2 years with little treatment offered.
Required ambulance transport to attend
On examination:
Oral condition poor with multiple retained roots
Sinus leaking pus above buried root of 24
Lower anterior teeth in reasonable condition
.
medications
- Want is to go to impact dentistry?
- What oral side effects?
Need more info, capacity etc
- How can we have prevented this?*
- Need to consider long term for pt – make their life easier in the future but take into account pt best interests
90 year old Female
-
2012
- First presentation for assessment of pain.
- 48,47 extracted and new F/P constructed.
-
2013
- 45 pain – filled then extracted a few months later due to pain.
- Lower lip and gum sore – shiny and atrophic appearance –
- GMP prescribed prednisolone mouthwash
- Diagnosed erosive lichen planus with associated vulval/vaginal pain: referred Dermatology
-
2014
- 33,34 extracted due to pain – poor healing and evidence of MRONJ
- Seen at oral medicine clinic then as a domiciliary – ability to leave house reduced
- Multiple treatments tried including tacrolimus – condition failed to resolve satisfactorily (for lichen planus – had sores, lesions)
Medical History:
Angina; arthritis; asthma; knee replacement; ischaemic heart disease; osteoporosis; chronic kidney disease; xerostomia; xerophthalmia
Medications:
Carbocisteine; carbomer eye gel; citalopram; fluticasone proprionate and salmeterol cfc free inhaler; folic acid; furosemide; GTN spray; hypromellose eye drops; isosorbide mononitrate; Oral Balance® gel; paracetamol; risedronate sodium; salbutamol; tiotropium;
- Exposed bone for over 8 weeks that wasn’t healing and medications - MRONJ?*
- treatment considerations*
- likely had constant pain for years due to lichen planus
- Is she is the best place? QoL?
Tx complicated but need to take into account QoL
equilbrium of oral biofilm disease
Oral biofilm-based diseases are controllable
If we get the balance right…
- Reasonable oral health, without pain or infection
- Oral comfort to allow for social interaction
- Limit operative dental care
- Avoid the challenges associated with sedation
- Avoid the significant morbidity and risks associated with General Anaesthesia
- Move away from pharmacological approaches to care to embrace philosophies centred around the individual
Socransky complex causes of aspiration pneumonia
- 58 year old male
- Diagnosis of rapidly progressing early onset dementia
- Has recently moved into a care home
- Wife is welfare power of attorney
- Supported in self-care
Clinical Findings
- Relatively co-operative for assessment
- Retained roots 15,11,23,34 and 47
- Previous left-sided facial swelling (treated with antibiotics by GMP)
- Stable periodontal condition
- Removable partial maxillary denture
Assessing capacity
- The clinician to patient interaction
- Does this person have capacity to make a decision?
- What treatment would you provide in this situation?
Benefit
- Retained roots with chronic infection
- Dementia likely to deteriorate to a point where all co-operation for treatment is lost
- There is benefit to keeping some teeth for retention of a denture, function, aesthetics and quality of life
Minimum necessary intervention
- How well is the person able to tolerate dental treatment
- Do you actively treat or do you palliate?
- Minimum necessary intervention does not mean do nothing
Take account the wishes of the adult
- What were this person’s feelings about their teeth
- Consultation with people who knew him may give more information
- What are his opinions just now?
Consultation with relevant others
- The patient’s wife has Power of Attorney
- She must be consulted prior to any treatment being performed
Encourage the adult to exercise ‘residual capacity’
- Although this person has dementia it does not mean he is incapable of making a decision
- Should be included in this process
- Re-assessment of capacity at each visit to determine level of capacity
assessing capacity of
- 29 year old male
- Moderate Learning disability
- Attends with a carer
- Carer reports patient being off food recently
- Won’t let anyone help with brushing his teeth
Clinical findings
- Buccal swelling associated with 23
- Multiple retained roots
- Multiple carious teeth
- The clinician to patient interaction
- Does this person have capacity to make a decision?
- What treatment would you provide in this situation?
- The clinician to carer interaction
- What information you need to require and how to obtain to
considerations
- 29 year old male
- Moderate Learning disability
- Attends with a carer
- Carer reports patient being off food recently
- Won’t let anyone help with brushing his teeth
Clinical findings
- Buccal swelling associated with 23
- Multiple retained roots
- Multiple carious teeth
Benefit
- Infection is present
- Number of carious teeth which require intervention to prevent further infection
Management of the emergency situation
- Poor co-operation to attempt removal of roots as source of infection
- Unable to consult with legal guardian
- Indication for the use of antibiotics but definitive treatment planning is required
Minimum necessary intervention
- Significant treatment need and volume of treatment required
- Poor co-operation at initial visit
- Minimum necessary intervention may well be the provision of care under general anaesthetic
Take account the wishes of the adult
- What is the patient able to communicate about their wishes?
- Previous experience of treatment may give some clues
Consultation with relevant others
- Important to contact the legal guardian prior to the provision of non-emergency treatment
- It is important to clarify the legal position of the person and documentation must be seen
Encourage the adult to exercise ‘residual capacity’
- There is a responsibility to allow the individual to use what capacity they do have to express their views
- This may require the use of communication adjuncts
