26
Geriatric Oral Medicine
Katharine Ciarrocca, DMD, MSEd
Christine Downey, DDS, MS
Population aging—the shift in distribution of a nation’s population to older ages—is occurring globally, with nearly all countries worldwide demonstrating population growth in older persons.1 In 2019, there were 703 million persons aged 65 years or over globally, with this number projected to more than double to 1.5 billion by 2050.2 People are living longer, and for the first time in recorded history most individuals can expect to live at least into their 60s, with current global life expectancy at birth being 72.3 years.2 Population aging was first evident in higher‐income countries, such as Japan, where 30% of the population is already older than 60 years.2 However, low‐ and middle‐income countries (such as China and Iran) are currently experiencing the greatest rate of population aging.2 Even more pronounced is the increase in the world’s population over 80 years, which nearly tripled in the past 30 years to nearly 143 million and is projected to triple again to 426 million by 2050.2 In countries such as the United States, the number of people in the “oldest old” age group (>85 years) is projected to reach 18 million and account for 4.5% of the US population by 2050, up from 2.5% in 2030.3,4 Finally, living to 100 is becoming increasingly common. Worldwide there are approximately 533,000 centenarians, with the United States having the highest absolute number at 72,000.5 Japan has the highest rate of centenarians, who account for 48 in every 1000 Japanese.5,6
The growth in the number of older adults worldwide can be attributed to a variety of factors. First, advances in medicine and public health have led to a notable increase in life expectancy. A significant reason for the “graying” of the population is the aging of the baby boomer generation. For example, in the United States, the first baby boomer turned 65 in 2011. The last baby boomer will turn 65 in 2030, creating a demographic where one in every five Americans will be over the age of 65 (see Figure 26‐1).7 With this dramatic change in the global landscape and the improved medical management of disease, oral healthcare professionals must possess the tools and knowledge to treat older adults comprehensively, keeping in mind their oral manifestations of systemic disease and their age‐related specific oral changes.
Figure 26‐1 Population growth projections (2016–2034).
Reproduced with permission from https://www.census.gov/content/dam/Census/library/visualizations/2018/comm/pop‐projections‐1.jpg.
CONCEPTS OF AGING
The age of 65 years was selected as the dividing line between middle‐aged and elderly individuals in the late 1880s in Germany as a criterion for Social Security, and was adopted worldwide, mainly for the determination of pension and retirement systems.8 It is now the accepted chronologic age for the elderly; this number is arbitrary, as aging is both chronologic and functional. The chronologic definition of age is simply a number. The functional definition, however, is based on the ability of the individual to travel to seek services. This assessment of how a person functions in daily life makes the functional definition of age much more appropriate than a chronologic one.9 There are three functional age classifications:
- Functionally independent older adults or those who are physically well despite advanced age.
- Frail older adults or those at high risk for major adverse outcomes.
- Functionally dependent older adults or those who have experienced deterioration of physical capacities and must rely on assistance from others.9
The majority of older adults (78%) live in the community, approximately 5% of these people are homebound, and another 17% have a major limitation in mobility due to a chronic condition.10,11 This leaves about 70% of the entire elderly population living in the community and capable of traveling to seek services independently, including to the dental office for oral healthcare.
Aging, systemic illness, and its’ management directly influence oral health, function, and the provision of dental care.12,13 Because older adults are more likely to utilize dental healthcare services compared with previous older generations,14,15 oral health professionals must be able to recognize, diagnose, and manage oral conditions in the aging patient. This chapter will provide background on the etiology, clinical manifestations, and treatment of common oral conditions that affect older individuals. In addition, a comprehensive review of age‐related oral changes and the impact they have on oral health and the provision of dental care will be performed.
GERIATRIC PATIENT ASSESSMENT
The health assessment of an older adult can be quite different and significantly more complicated than the work‐up of a younger patient. A geriatric assessment differs from a standard evaluation, because it includes nonmedical areas that emphasize functional capacity and quality of life, yielding a more complete and relevant list of medical problems, functional problems, and psychosocial issues. A variety of validated tools can make geriatric assessment more specific for older patients, as these instruments evaluate domains such as activities of daily living (ADLs), hearing, fecal and urinary continence, balance, and cognition; none of which is typically evaluated in a younger patient.16 This assessment should also include a thorough review of prescription and over‐the‐counter medications and supplements, and also review of immunization status. An interprofessional team, which can include a primary care provider, nutritionist, social worker, pharmacist, psychologist, physical and occupational therapists, and oral healthcare professional, yields a more complete and relevant list of medical problems, functional problems, and psychosocial issues and therefore provides more comprehensive, whole‐person, person‐centered care.17
Dental treatment planning can also be complicated, as a multitude of factors affect decision‐making and provision of care. Limitations due to social, economic, financial, family, medical, physical, and transportation constraints must all be considered when formulating a comprehensive oral healthcare plan for an older patient.18 Treatment plan sequencing and communication of the plan can be challenging due to the variety of issues that complicate the progression of care. The final outcome can be difficult to predict, and therefore the treatment plan must be dynamic. Patient health may change as treatment proceeds, thus resulting in new treatment modifications that necessitate reassessment as well as communication based on these needs. Patients, their family, and their caregivers must continually be informed about their oral condition and the fact that treatment needs may change as treatment progresses. Optimal dental care for the geriatric patient requires an individualized approach that includes modifying factors and circumstances, such as disability that affects self‐care or length of appointment.19
Utilizing a systematic approach when assessing older patients can aid in the development and delivery of comprehensive treatment. This approach starts with an assessment that answers several basic questions specific to older adults:
- How does the patient function in their environment?
- What role does pharmacotherapy play in the patient’s medical and oral health?
- What social support systems for the patient exist?
- What diverse sociologic variables exist?
- How does oral healthcare fit into the patient’s environment?
Dental management of the geriatric patient is consistent with any medically complex patient and involves the evaluation of four risks and subsequent modifications to the provision of dental care. Risk of infection, risk of bleeding, risk of drug actions and interactions, and risk of medical emergency during dental care need to be evaluated before routine dental treatment begins.20 The elderly can be immunosuppressed or nonadherent with medications and instructions, therefore placing them at increased risk of infection. In addition, they may be taking anticoagulation medications or have a systemic disease that alters hemostasis. Depending on the invasiveness of the procedure, patients can be at increased risk of bleeding. The elderly are often taking more medications, are more sensitive to medications, may need renal dose adjustment, and have difficulty with drug compliance and accuracy.21 Finally, it is imperative to evaluate the ability to withstand treatment based on systemic disease and compliance in control of the disease, and also to ensure that the dental team is prepared for a potential emergency.
A multidimensional assessment tool for planning oral healthcare for the older patient has been developed by the American Academy of Oral Medicine.22 This tool is called OSCAR, a five‐item mnemonic for Oral, Systemic, Capability, Autonomy, and Reality. OSCAR serves to guide dentists in identifying the dental, medical, pharmacologic, functional, ethical, and fiscal factors that need to be considered before dental treatment of older patients. This approach enables the clinician to evaluate each older patient in a comprehensive manner, incorporating all factors that may affect care.
The OSCAR approach starts with patients’ oral needs and can include issues such as oral mucosal disease and periodontal and dental problems. Assessment of systemic factors is next and incorporates medical problems, medications, and collaboration with other healthcare providers to develop the treatment plan. Evaluating patients’ capability is very important and involves the assessment of functional capacity, ability to move and be moved, and even their skill in performing oral hygiene. Next is evaluation of patients’ autonomy, which assesses decision‐making ability, ability to communicate and understand, and even the ability to consent to care. Lastly, reality refers to financial issues, life expectancy, prognosis, and ability to perform oral hygiene and maintain oral health, which would affect the dental treatment plan. Taking each of these facets into consideration enables the clinician to provide patient‐centered care that is specific for each older patient (see Table 26‐1).22
PHARMACOTHERAPEUTICS IN OLDER ADULTS
Older adults make up approximately 15% of the US population, but are responsible for one‐third of all prescribed medications.23 Furthermore, it is projected that by 2040 older adults will be consumers of 40% of prescribed medications.24 Due to increased medication exposure, older adults are at greater risk for drug‐related complications. Problems such as drug–drug interactions, adverse drug reactions (ADRs), undermedication, polypharmacy (use of multiple medications or use of more medications than appropriate), and nonadherence are common among this population.25 In addition, numerous changes occur as a result of physiologic aging that alter the way medications are absorbed, distributed, metabolized, and eliminated.26 Medications therefore may need to be prescribed differently in this population by carefully choosing medications to avoid adverse effects or drug interactions, and adjusting doses to allow for functional changes of organs, such as the liver and the kidneys. Finally, certain medications may not be safe to use at all in older adults, and these are delineated in the Beers List of Medications to Avoid in Older Adults.27 (A more in‐depth understanding of the Beers List is addressed in what follows.)
Table 26‐1 OSCAR approach to evaluation and treatment of the older dental patient.
Source: Adapted from Laudenbach J, Jacobsen PL, Mohammad AR, et al. Clinician’s Guide: Oral Health in Geriatric Patients, 3rd edn. Seattle, WA: American Academy of Oral Medicine; 2011.
| Areas of Concern | |
|---|---|
| Oral | Dentition, restorations, fixed and/or removable prostheses, periodontium, oral mucosa, salivary glands |
| Systemic | Medical problem list, medications, age‐related changes, interprofessional communication |
| Capability | Ability to perform instrumental activities of daily living, activities of daily living, caregivers, oral hygiene, transportation, mobility |
| Autonomy | Decision‐making ability, consent to care, dependence on others for decisions |
| Reality | Financial limitation, life expectancy, prognosis, ability to maintain dental treatment, medical stability |
Pharmacokinetics
The pharmacokinetics of medications—absorption, distribution, metabolism, and elimination—can be altered due to the aging process. The absorption of medications is least affected. Most drugs are absorbed passively, simply by being in the stomach or intestine. If absorption is affected in older adults, it is usually decreased due to an increased amount of acid in the stomach, decreased movement of the muscles of the digestive system, or decreased surface area for absorption.28,29 Many medications are not significantly affected by these changes, but the coadministration of certain medications, such as antacids, can further decrease absorption. As a consequence of the age‐related changes in body composition, drug distribution can be affected. Drugs that are mainly water‐soluble tend to have smaller volumes of distribution, resulting in higher serum levels in older people. Lipid‐soluble medications have higher volumes of distribution, resulting in a prolongation of half‐life.29 Aging is associated with a reduction in first‐pass metabolism, likely due to a reduction of liver mass and blood flow. The result is a decrease in the bioavailability of medications that undergo an extensive first‐pass effect.28,29 Medications that are pro‐drugs, however, need to be activated in the liver and hence their activation might be reduced.
Drug elimination is affected by aging due to a decline in renal function. As the body ages, there may be:
- Decreased kidney size.
- Decreased blood flow to the kidneys.
- Long‐standing disease, such as diabetes or hypertension.29
The medication dose or dosing frequency may need to be altered; usually less frequent administration is needed, as it will take the body longer to eliminate the medication.
Pharmacodynamics
The pharmacodynamics of medications—the drug’s action on the body—can also be affected by the aging process. As we age, multiple changes occur, such as changes in body composition (increased body fat, decreased lean muscle mass, and decreased body water), which can affect frequency of administration and dosage of medication. Medications that are lipophilic may have prolonged effects due to the increased amount of body fat. Drugs that are hydrophilic may have a more rapid increase in concentrations in the blood because there is less water. These changes often necessitate lower dosing of medication.28, 29 Drugs that are highly protein bound, however, have less protein upon which to bind, therefore more of that medication may be required for it to be effective. Finally, as adults age they may experience decreased or enhanced effects of drugs compared to younger populations. Changes occur at the medication’s receptor site of action and can ultimately affect the way the body responds to the medication. For example, some older patients are susceptible to medications that cause sedation as a side effect. Sedation can have multiple comorbidities: risk of falls, confusion, and the inability to perform daily tasks.28,29
Polypharmacy
Polypharmacy is the use of multiple medications and/or the administration of more medications than are clinically indicated.30,31 Polypharmacy may also be described as the use of one medication to treat the side effects of another medication, rather than changing to medication that may be better tolerated.32 Polypharmacy is common among geriatric patients: 87% report taking one prescription medication, 36% report taking five or more prescription medications, and 38% use over‐the‐counter medications.32 The likelihood of receiving a prescription increases with age, and polypharmacy may increase the incidence of ADRs as well as drug–drug interactions. Adverse drug events are responsible for one in six older adults being hospitalized.33
Medication Adherence
Medication adherence is the extent to which a patient’s use of medications coincides with medical or health advice. Medication adherence is a significant problem among the geriatric population. Over 70% of Medicare beneficiaries take prescription medications, but as many as 30% are nonadherent.34 Complex medication regimens, misunderstanding medication importance, forgetting to take medication, not getting medication refilled, worry about side effects, lack of understanding of indication, and cost all may contribute to decreased adherence.34 Underprescribing appropriate medication can also occur in the medical management of older patients. Some medications may be underutilized for conditions such as pain, because of concerns about adverse effects or polypharmacy in the geriatric population.35 Overall, concerns related to comorbidities, adverse drug events, limited life expectancy, and poor risk‐to‐benefit ratio can all be reasons why prescribers are more hesitant to write for indicated medications.36
The Beers Criteria
The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults was originally developed in 1991 by the late geriatrician Mark Beers as a catalogue of medications that cause adverse drug events in older adults due to their pharmacologic properties and the physiologic changes of aging.28 Beers developed a list of medications, doses, and durations that should be avoided in patients older than 65 years in nursing homes. The list was created from expert consensus through extensive literature review. Since 2012, Beers Criteria have been revised every three years in order to be applicable to all adults 65 and older regardless of where they reside, and include criteria specific to diagnosis and condition. In 2019, the American Geriatrics Society (AGS), utilizing an enhanced, evidence‐based methodology, published updated AGS Beers Criteria® to improve medication safety in older adults.27 Each criterion on the list was rated by quality and strength of evidence, using the American College of Physicians’ Guideline Grading System.28 For the 2019 update, an interdisciplinary expert panel reviewed the evidence published since the last update (2015) to determine whether new criteria should be added or existing criteria should be removed or undergo changes to their recommendation, rationale, level of evidence, or strength of recommendation. Five criteria were used to eliminate 25 medications from the list published in 2015:
- Medications that are potentially inappropriate in most older adults.
- Those that should typically be avoided in older adults with certain conditions.
- Drugs to use with caution.
- Drug–drug interactions.
- Drug dose adjustment based on kidney function.27
Printable Beers Pocket Cards are available for download.36
Tools for Medication Assessment
Medication use in older adults can be complicated. Each person is different and all geriatric patients may not have the same degree of impairment, so an individualized approach is of the utmost importance. Evaluation of medications in the geriatric population is vital to ensure that medications are used appropriately and safely. Studies have shown that as many as 40% of nursing home residents in the United States were prescribed inappropriate medications.37
There are both implicit and explicit tools used to assess medication appropriateness. Implicit tools utilize patient‐specific information and prescriber clinical judgment and experience to address questions, statements, and algorithms in order to optimize medication regimens.38 Implicit tools enable healthcare providers to identify both the medications that should be avoided as well as the incorrect doses, drug interactions, and patient preference. Examples of implicit tools—the Medication Appropriateness Index (MAI) and the ARMOR tool—are discussed in this section.38,39 Explicit tools, on the other hand, do not consider patient‐specific factors in determining medication appropriateness and comprise lists of medications developed by consensus panels after extensive literature and database review. An example of an explicit tool is the AGS Beers Criteria previously discussed.27 Explicit tools can be used by anyone regardless of discipline to determine the appropriateness of prescribing, but are limited to medications recognized by the tools’ developers. In contrast, implicit tools can be applied to any medication, but require clinical judgment and an understanding of physiology and pharmacology.
The MAI is a tool that uses implicit criteria to rate medications in order to reduce polypharmacy and inappropriate prescribing.38 Its is very reliable and is structured in a way to evaluate medication use in geriatrics. Even when different clinicians evaluate the regimen, the results are generally similar. The MAI covers 10 elements of appropriate prescribing.38 It is useful in a variety of situations, including patients in the community and hospital settings.38
The ARMOR tool is used to Assess, Review, Minimize, Optimize, and Reassess medication regimens (see Table 26‐2).39 The goal of ARMOR is to improve a patient’s functional status and mobility. The tool was designed for nursing home residents receiving more than nine medications, seen for initial assessment, with falls or behavioral disturbance, or who are admitted for rehabilitation.39 This tool was tested in a long‐term care facility and was evaluated by a multidisciplinary team from medicine, nursing, physical/occupational therapy, recreational therapy, and social work. The ARMOR tool can also be utilized for all geriatric individuals and has led to a reduction in polypharmacy, cost of care, and hospitalization.39
Table 26‐2 ARMOR tool of medication assessment.
Source: Adapted from Haque R. ARMOR: a tool to evaluate polypharmacy in elderly persons. Ann Longterm Care. 2009;17:26–30.
| ARMOR |
|---|
| Assess the patient for the total number of medications with a potential for adverse effects (beta blockers, antidepressants, antipsychotics, pain medications, medications on the Beers criteria) |
| Review medications for possible drug–drug interactions, drug–disease interactions, pharmacodynamic (how drugs act in the body) interactions, impact on function, and adverse effects |
| Minimize the number of nonessential medications, particularly medications with a clear lack of evidence, or if the risk outweighs the benefits of using the medication |
| Optimize therapy. Evaluate duplicate treatments, adjust doses for kidney or liver function, and adjust doses to achieve treatment goals |
| Reassess the patient and medications using information such as heart rate, blood pressure, oxygen saturation, functional status, cognitive status, and medication compliance |
Geriatric patients are more likely to be on multiple medications, many of which can complicate the provision of oral care. It is therefore imperative for oral healthcare professionals to evaluate patient medications in the context of pharmacokinetics and pharmacodynamics, potential adverse reactions, and complications as a part of the comprehensive oral/medical evaluation. A 2018 study showed that over 75% of patients surveyed are aware of the importance medications have in interacting with dental health and treatment, and consequently disclose all medications prior to dental care.40 The dental team can therefore provide evaluation of medication adherence and reconciliation as part of whole‐person care.
HEALTH LITERACY
Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decision.s”41 Health literacy is not only the ability to read, as it also involves listening, analyzing, and decision‐making together in healthcare situations. Patients may be well educated and knowledgeable in any number of areas, but may have limited knowledge about health and healthcare. Findings of the 2003 National Assessment of Adult Literacy revealed that although the majority of adults in the United States had intermediate or proficient literacy, 36% had only basic or below basic health literacy.42
Results of this survey also revealed that compared to adults in younger age groups, adults aged 65 years and older had lower average health literacy. Among adults aged 60 years and older, 71% have difficulty using print materials, 80% have difficulty using documents such as forms or charts, and 68% have difficulty interpreting numbers and performing calculations.42 In addition, estimates suggest that 66% of older adults are not able to understand information received about their prescription medications.43 Activities requiring health literacy include communicating with clinicians about health and illness, reading and understanding health information, taking medications, making appointments, and filling out medical forms.42,43
Health literacy is especially important among the geriatric population because it affects a patient’s ability to navigate the healthcare system, share personal and health information with providers, engage in self‐care in chronic disease management, and even adopt health‐promoting behaviors. Low health literacy is associated with increased use of inpatient and emergency care, decreased use of preventive and primary care, and deficits in self‐care. Limited health literacy also leads to underutilization of services, poor understanding of health, poor health outcomes, and increased healthcare costs.44
Table 26‐3 Teach‐Back method: confirmation of understanding.
Source: Adapted from Stein PS, Aalboe JA, Savage MW, Scott AM. Strategies for communicating with older dental patients. J Am Dent Assoc. 2014;145(2):159–164.
| Do not ask a patient “Do you understand?” |
| Ask patients to explain or demonstrate |
| Ask questions that begin with “how” and “what,” rather than closed‐ended, yes/no questions |
| Organize information so that the most important points stand out and repeat this information |
| Ensure agreement and understanding about the care plan. This is essential to achieving adherence |
The entire oral healthcare team must be aware and sensitive to the effect health literacy has on the provision of care.44,45 Some simple strategies are as follows:
- Explain things clearly to the patient using nonscientific, plain language, starting with the most important information first.
- Emphasize one to three points and encourage questions.
- Provide written instructions for important information and provide useful educational materials.
- Use the teach‐back method to confirm the patient’s understanding. This approach has the provider ask the patient to describe and/or demonstrate the information that has been explained. This is accomplished by asking open‐ended questions (e.g., do not ask the patient, “Do you understand?”).46,47
- Ensure agreement and understanding about the care plan; this is essential to achieving adherence (see Table 26‐3).47
COMMON CHRONIC CONDITIONS AND LEADING CAUSES OF DEATH
Advances in medical treatment and effective public health strategies have contributed to a striking increase in average life expectancy. Since 1900, global average life expectancy has more than doubled and is now above 70 years.48
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