The geriatric patient: psychophysiological factors associated with aging and dental anxiety
The world’s population is increasing at an annual rate of 1.2%, while the population of individuals over the age of 65 is increasing at a rate of 2.3%.1 Today, approximately 600 million people are over the age of 65, and that number is expected to double by 2025.2 By 2050, it is estimated that there will be 2 billion elderly individuals, 80% of them living in developing countries. Those over 80 years of age will make up 20% of the world’s population.3 The growing number of elderly people represents an enormous challenge to health providers in all countries. People are living longer, thanks in part to advancements in scientific research, medicine and technology. The elderly population ranges from those who are very healthy, vibrant, and living independently to those who are medically compromised with numerous physical and psychological problems that influence their ability to care for themselves.
Age and the risk factors associated with chronic diseases are also common to most oral diseases. The World Oral Health Report 2003 4 stressed that oral health is an integral component of general health, and an important component of the quality of life (QoL). The relationship between oral and general health becomes more evident as age increases. General and associated oral health conditions directly affect the QoL, manner and lifestyle. The many physiological and psycho-social changes associated with aging can have profound effects upon quality of life in later years.
This chapter reviews the major changes associated with aging with a focus upon the psycho-social aspects of aging, and provides strategies for effectively managing the older dental patient. The process of aging is a slow, progressive decline in the physiologic reserve, such that the person loses some of the ability to adapt and becomes more vulnerable to minor changes and stresses.5
Culture ethnicity and sociodemographic factors in fluencing age and oral health-related quality of life
Worldwide increases on life expectancy make the issues of cultural and ethnic differences in the aging experience an important consideration today, more than in previous times. People born in developed countries today can expect to live some four decades longer than their counterparts born at the beginning of the twentieth century. The reduction of the number of young people entering the world’s population, due to decreases in the fertility rate combined with increased and better medical care, which has increased longevity, has led to an increase in the ratio of older people in the world’s population.6
Ethnic and cultural minorities begin old age with a variety of disadvantages. They are more likely to be associated with poorer health, do not score well in physical and cognitive function tests, report greater number of medical conditions, and on the whole are less wealthy and possess incomplete and poorer health insurance. They may also be less educated, have labored over more difficult occupations, and have had with lesser amounts of medical care in their early childhood days.
The relevance of culture and ethnicity for the aged can sometimes be seen in the variations of treatment and respect of the aged person. In developing countries, esteem and respect for the elderly is greatly visible, while in well-established and developed countries, reports of neglect and the uncertain status of the elderly are increasing. Also, in developing countries, many of the young individuals travel to the larger cities seeking employment, thus reducing the availability of family caregivers.
Ethnic and cultural groups also vary in their dedication to providing family care. African Americans sanction the primacy of family care over white Americans, and are less likely to utilize long-term facilities for their aged such as nursing homes. Similarly, Latinos and Latinas, delay placing their elderly into long-term care facilities relative to white individuals. According to Alpert,6 ethnic and racial minorities are less likely to take advantage of preventive health services, such as required vaccination and prescreening test for a variety of diseases.7,8 In 2006, Makhija et al. noted that dentate and edentulous individuals, African Americans, those with less than a 6th grade education, and people earning less than $16,000/year, particularly when, combined with transportation difficulties, were more likely to have decreases in their oral health-related quality of life (OHRQoL). In the dentate group (those with dentition), transportation, race education, and income were associated with decreased OHRQol, while in the nondentate group (endentulous) only race and education were the major factors.9,10 This is not meant to infer that other variables were not as important for the edentulous person. In a study in the United Kingdom in 2001, McGrath and Bedi11 found that the OHRQoL was affected by age, employment status and ethnicity. Many times access to and use of dental care by older edentulous individuals is far less than for those individuals that have dentition.
Thus, cultural and socio-economic factors may play important roles in the ultimate oral health of elders.
Physiological changes associated with aging12–8
The process of aging involves a progressive decline in physiological function, often leading to decreased function and increased susceptibility to minor changes and stresses.5 However, the aging process varies tremendously among individuals, so it is important to avoid stereotyping or “ageism.” Chronologic age and functional age are often very different.
In general, the aging process may involve overall decreasing vigor and energy accompanied by:
- sensory impairment (declines in hearing, sight, smell and taste);
- lower vital capacity;
- slower nerve conductivity;
- decreased number and function of muscle cells (in association with decreased activity); and
- declines in organ system function.
Changes in muscle and tissue function
There is a steady decline in the efficiency of all physiological mechanisms with age, becoming more rapid after the mid-sixties. The generalized loss of muscle mass can make chewing, swallowing and speaking difficult, a problem common to edentulous patients. Sagging facial muscles adversely contribute to the patient’s ability to adapt to dentures, hindering ability to chew, swallow, and speak. The amount of subcutaneous fat declines, and the skin becomes less elastic as individuals age. The lining of the oral cavity also becomes more friable with age.
Basal metabolic rate decreases and may be associated with increased weight because fewer calories are utilized each day due to reduced activity, especially for individuals aged 65 and older. Malnutrition is often seen, secondary to a disease condition or as a result of factors associated with aging.
Changes in cardiovascular functioning
Cardiovascular functioning declines with age as blood flow to the central and peripheral vessels decreases. Although the heart may pump harder, it achieves less, resulting in decreased cardiac output. Arterial walls rigidify, myocardial contractions lessen, and peripheral resistance declines. Atrial fibrillation is often seen with increased age; many individuals suffer from coronary artery disease and hypertension. The treatment of cardiovascular diseases often has an impact on oral health and dental treatment, for example, some medications have side effects causing xerostomia and orthostatic hypotension. The decline in peripheral blood flow is also associated with a loss of skin tone.
Intestinal tone and decline in digestion and absorption can lead to the constipation and abdominal discomfort common with elders. Misuse of laxatives can result in potassium depletion. The unpleasant feeling of constipation can lead to the avoidance of proper eating, leading to malnutrition.
Bone physiology also changes with age, with bone resorption exceeding deposition, resulting in a net loss of bone mass. There is a progressive decrease in overall skeletal mass, often leading to osteoporosis and bone fractures. Severe bone loss results in vertebral fractures, low back pain, a stooped position, and subsequent loss of height.
Decreases in renal function can have far-reaching effects, especially dehydration. Decline in the ability to recognize thirst with age may result in decreased water consumption. The associated dehydration can cause changes such as skin wrinkling, collapse and wrinkling of facial tissues, and diminished tear production, resulting in dry eyes. Loss of total body water directly affects drug therapy, necessitating constant adjustments in dosage. Severe dehydration can be fatal. Bladder muscles also weaken with age, often leading to incontinence.
Decreased ability to smell foods combined with the reduced action of the taste buds is a contributing factor to malnutrition in the aged population.
Loss of sight and hearing frequently occurs with aging and can affect an individual’s overall attitude, increasing fears and anxiety often leading to improper sleep habits. Accumulation of wax and exfoliation of surface tissue cells in the ear canals may interfere with hearing. Hearing loss sometimes can be associated with imbalance and ability to communicate properly due to failure to hear completely what is being communicated. The eyelids are often affected, and droop due to loss of elasticity.
Impairment of vision in the form of macular degeneration, cataracts retinal detachment, and glaucoma are some of the chronic eye disorders affecting the older person. Blindness may be associated with diabetes retinopathy, trachoma, and leprosy, according to Schembri and Fiske.19 Visual impairment can alter an older person’s ability to maintain oral health, and to recognize the early signs of dental disease, such as bleeding when brushing, loss of a filling, or detecting a small cavity. The degree of periodontal disease may be higher because of the difficulty of attaining adequate oral hygiene owing to a diminished ability to see if gums are bleeding or plaque and stain have been sufficiently removed. For visually impaired elderly individuals, particularly those in residential homes, the risk of root caries is exceptionally high due to poor plaque control, diets high in refined carbohydrates, and xerostomia, usually the result of medications.
Changes in the immune system
With age, the immune system becomes less effective and less protective against infections. There is a decline in T cell function and production, impairing the ability to resist infection. Wound healing and repair is also influenced by aging, often slowing as age increases. The result is increased susceptibility to infection.
Reproductive systems also change with age in both males and females, but are more obvious in the female, in association with menopause. Menopausal symptoms can interfe with sleep and daily activities. The occurrence of hot flashes during dental appointments may cause a patient to feel uncomfortable and embarrassed leading to increased anxiety and even avoidance.13 Oral changes occurring in postmenopausal woman may include:
- insufficient saliva and the resulting increased risk for dental caries;
- taste alterations;
- atrophic gingivitis;
- increased periodontitis; and
- jaw osteoporosis (this can be a contraindication to dental implant placement).
Oral changes associated with aging
The oral changes associated with aging are many. Defoliation of the tongue, with subsequent decline in taste bud function, often results in decreased ability to taste foods. Gingival recession and the prevalence of periodontitis seem to correlate strongly with advancing age. Gingival recession with subsequent exposure of root surfaces is common, and may be partially related to inadequate blood flow. Cardiovascular diseases, such as stroke and coronary heart disease, are associated with tooth loss and severe periodontal disease.12
Increase in dental caries, including root surface caries, is common in the elderly, in association with xerostomia. Broken teeth and lost restorations are also frequent findings. Tooth loss can lead to many problems, including migration of adjacent teeth, malposed teeth, and malocclusions. Food may become trapped in spaces, which also may cause difficulty with chewing and swallowing as well as leading to periodontal problems. Temporomandibular joint dysfunction may follow due to malocclusion and drifting, as well as loss of teeth. After years of habits, such as bruxism, teeth may be severely worn, unaesthetic, and fractured.
Improvements in health care, longevity, and social conditions have led to people living longer and having an associated increase in periodontal disease expectancy. Aging itself, however, does not cause a significant loss of periodontal attachment in the healthy elderly individual.20 The effects of aging are based on biomolecular changes of the cells of the periodontium that accelerate bone loss in elderly with periodontitis. These effects may be associated with:
- alterations in differentiations and proliferations of osteoblasts and osteoclasts;
- increase in periodontal cell response to oral microbiota and mechanical stress; and
- systemic endocrine alterations in elderly individuals.
Chronic infection inherent in periodontitis may also be associated with cardiovascular events.21–24
Periodontal conditions have been related to carotid calcifications in the elderly.25 In one study, cardiovascular disease, diabetes and rheumatoid disease were all significantly correlated to the number of teeth lost.26 Edentulous individuals also appear to be at a greater risk of coronary heart disease and premature death.27
Xerostomia and root caries
Xerostomia, a condition of decreased salivation, in association with dryness of the tissues of the oral cavity, is prevalent in elderly individuals. The most common cause of xerostomia in aged individuals is their medications, but it can also result from systemic diseases such as diabetes, Sjogren’s syndrome or AIDS, or from the effects associated with treatment of these disorders. Cancer of the head and neck and associated radiation and medications also play a role in decreased salivation.28–31 The QoL can be affected by xerostomia as the disorder affects chewing, swallowing and speech.32 Saliva provides many protective functions in the oral cavity (cleansing, lubricating, remineralizing, antibacterial, etc.). So hyposalivation can present difficult challenges to the sufferer and the dental practitioner. Xerostomia has been identified as one of the major risk factors associated with caries among elderly individuals. Studies of dental caries in the aged population have reported high incidences of coronal and root caries.33–37 In studies by Papas et al.,38,39 it was noted that patients with medication induced xerostomia tend to be more susceptible to root caries than healthy individuals. As recession occurs in older individuals, the root surfaces having less mineralization than the coronal surfaces, are far more susceptible to decay.
Oral bone and soft tissues
Removable appliances often present a wide array of discomfort issues caused by dryness or loss of alveolar bone. Alveolar ridge resorption in both the mandible and/or maxilla occurs, leading to problems with retention of removable prostheses and associated irritation. As age increases, one often sees the development of hyperplastic tissues, denture stomatitis, angular chelitis, papillary hyperplasia, as well as ulcerations.
Oral cancer and precancerous lesions
The risk of oral cancer increases as one ages. Cancerous lesions of the oral cavity and pharynx have higher mortality rates than other types of cancer. Elderly individuals are at greater risk for the development of precancerous lesions and oral cancer. Risk factors associated with development of these lesions are mainly smoking and alcohol consumption.40,41 A study by Epstein, Lunn, and Le42 noted that a decline in the elderly individuals’ defensive mechanisms, combined with the presence of common risk factors related to oral and general health and to lower psychological and socioeconomic status, had a great impact on cancer survival in that age group. Precancerous lesions such as leukoplakia are often seen occurring in the elderly, especially those within the lower socioeconomic level.43
Patients may be at risk for cancer, presently have it, or have been treated for various forms of it. The practitioner must assess for all risk factors, including those for oral cancers, as well as for the head and neck. This assessment is necessary so that modifications of the patient’s behaviors can be instituted to reduce risks and attempt to prevent any occurrence of cancer. Before any cancer therapy is instituted, the patient should be instructed in the performance and maintenance of meticulous oral hygiene practices. During treatment, especially for head and neck tumors, continuous preventive practices must be maintained, as well as palliative treatment for mucusitis and xerostomia. After treatment, maintenance of oral hygiene instruction and practices, salivary substitution agents, sialogogues, fluorides, diet modification suggestions should be implemented, together with assessment for depression, quality of life issues, function, pain and difficulty swallowing.
Psychological and QoL risk factors associated with aging
Ettinger and Beck44,45 classified older individuals into three categories according to psychosocial function:
(1) the functionally independent older adult;
(2) the frail older adult; and
(3) the functionally dependent older adult.
Those individuals in the first group mostly remain independent even in the presence of chronic medical problems requiring continuing medical attention. Older individuals in the other two groups require aid in maintaining basic levels of personal care. The third group is composed mostly of those individuals requiring special care either in the home or in longterm facilities. Factors such as low income, low education, and reduced community support have been shown to be closely related to functional impairment. The more dependent a person is, the greater is the risk of burden by diseases such as:45
- mental disease, for example, depression, dementia;
- Alzheimer’s or Parkinson’s disease;
- visual and hearing impairments;
- unintended weight loss, inadequate nutrition;
- dry mouth; and
- orofacial pain.
Declines in mental health status can complicate other health issues in the elderly. With increased levels of dementia and memory loss, decisionmaking capacity is reduced. This may interfere with a person’s ability to perform adequate oral hygiene procedures. Alzheimer’s disease is the most common cause of dementia in the older person. Dementia may have a negative effect on the oral health of older individuals, and may result in higher levels of edentulism.12,46–49 The demands of day-to-day care, changing family roles, and difficult decisions about placement in a long-term care facility place additional stress on the caregiver and family support structure.
Depression, dementia, and paranoia
Elderly depressed patients are more likely to complain about physical problems as opposed to mood changes. They may also exhibit weight loss, complain of general aches and pains or difficulty sleeping, and shows evidence of impairment in physical, mental, and social functioning.50,51 Dementia and paranoia are also psychiatric illnesses affecting the aged. Although not entirely inherent to aging, the aging process does increase the risk of such illnesses occurring. Dementia is a disorder characterized by deterioration in the intellect, cognitive abilities, behavior, and emotions. It may be due to any number of causes such as:
- decline in overall general health;
- pharmacological agents; and