Older adults have multiple morbidities that can impact oral, systemic, and psychological health. Although each disorder requires consideration from the provider before treatment, by assessing the common phenotypic presentations of older adults, we can better understand, select, and coordinate treatment modifications that would need to be considered and implemented for dental care.
Older adults have multiple morbidities that can complicate their systemic health and their oral health.
Examining the most common geriatric phenotypes and their relationship to oral disorders helps the practitioner to prepare for and deliver appropriate care.
Patient-centered dental clinical practice guidelines for older adults are lacking.
Using the existing guidelines for older adults may lead to fragmented and inefficient care, as well as increased costs.
Interprofessional teams are important in the dental care of older adults.
Many countries have been tracking the changing proportion of adults 60 years of age and older within their borders, with most demonstrating some level of growth. From a global perspective, individuals 60 years of age and older made up 11% (605 million) of all people; there are projections of the world’s population of adults 60 and older doubling to 22% (2 billion) by 2050.
With increasing longevity have come higher rates of morbidity owing to chronic disease. Current studies demonstrate 80% of older adults having at least 1 chronic condition with 40% having 2 or more. This coexistence of chronic systemic diseases has been termed multimorbidity or comorbidity. Epidemiologic studies have shown that multimorbidity is associated with an increased risk of death, disability, poor functional status, poor quality of life, adverse drug events, and other unfavorable results.
Morbidity clusters have also been described, with certain diseases seeming to show a propensity to occur simultaneously, for example, hypertension and diabetes. Similarly, comorbidity and clustering can happen with oral conditions, for example, salivary hypofunction and caries. If one were to look at comorbidities across the spectrum of oral, systemic, and psychosocial factors, it is likely that other clusters would be found, potentially influencing each other; for example, oral lesions that could impact nutritional intake, diabetic control, and/or deter individuals from participating in communal nutritional breaks and thus negatively impacting socialization. In addition to unattended pain found with oral lesions, decreased quality of life, loneliness and depression may coexist.
The appreciation of the human emotional and economic toll caused by aging and chronic diseases has caused agencies to attempt improvements to the functional years of life through health care advances. The development of evidence-based, clinical practice guidelines is an effort to optimize the treatment of chronic diseases such as hypertension or coronary artery disease. Most commonly, these guidelines have a singular disease focus, not considering the impact of other possible comorbidities. When diseases are treated as stand-alone, overtreatment is likely. The input of an interdisciplinary team thus becomes vitally important to manage these medically complex patients; involving other professionals from the entire health system spectrum helps to minimize overtreatment and provides a more appropriate holistic approach.
In addition, clinical practice guidelines are not generally constructed with the patient at the center, often focusing on immediate medical or physiologic concerns with little notice of barriers that might impede the actions recommended by the guidelines, assessment of changes in overall functionality, or consideration of the patients’ or caregivers’ concerns. For older adults, clinical practice guidelines need to be centered on the multiplicity of findings often seen in older patients and on efforts to promote coordinated care across clinicians and settings. Owing to the current lack of these systems, fragmentation, inefficiencies, and increased costs result from clinical practice guideline use.
Dentistry has few clinical practice guidelines, with those that do exist (eg, prophylactic antibiotic use for certain cardiac or joint replacement conditions), also placing the disease at the center rather than the patient’s and family’s goals, as recommended by the National Quality Forum. Nor has dentistry created clinical practice guidelines that cross disciplines and consider the intersection of chronic systemic disease with oral health conditions and psychosocial issues. Yet, those with systemic multimorbidities are more likely to seek dental care than those without this finding; a number of studies have demonstrated high morbidity relationships, especially in the edentulous patient.
It is in the patient’s best interest for oral health care practitioners to prepare to care for more older adults with multiple chronic systemic diseases, more episodes of oral disease, and interposing psychosocial influencing variables. There are multiple conditions seen in older adults that can present with similar phenotypes. For this reason, in this article, we take a broad approach, presenting various common phenotypes and including examples of oral findings and oral treatment implications for each topic.
Infection and inflammation
Immunosenescence describes changes in the immune system’s capability that occur with advancing age in the absence of disease; such changes normally cause only modest decreases in immune function. This impact becomes more substantial when other conditions coexist (eg, malnutrition, diabetes, human immunodeficiency virus, etc). When dysfunction is severe, autoimmunity, diminished surveillance capability, and increased susceptibility to infections arise.
Even when inflammation is low grade, it has an effect on aging. “Inflammaging” describes this proinflammatory state, considered to be a proxy marker and influencer of aging progression. Inflammaging impacts disease susceptibility, is a part of multimorbidities such as frailty, and causes an overall lessening of physical, cognitive, and life span capabilities. Fig. 1 displays the relationship between lifespan aging and inflammation. If inflammation occurs in the short term, it is part of the body’s natural defense mechanism and causes no lasting effects; however, when a source of infection and inflammation is prolonged, such as is seen with periodontal disease and caries, systemic diseases (eg, atherosclerosis, diabetes, kidney failure, and neurodegenerative disorders including Alzheimer disease) are negatively impacted.
In addition to chronic conditions, intraoral bacteria can also directly cause serious acute systemic infections, such as endocarditis, brain abscesses, septic arthritis, and infections of joints and bone, and increase the risk for aspiration pneumonia, yet another reason to eliminate any intraoral inflammation. Exposure to infectious agents causes inflammation that can influence the progression of atherosclerosis; periodontal treatment to remove inflammation could diminish the risk of myocardial infarction and stroke in older adults. Epidemiologic evidence also links periodontal disease with diabetes and predisposes patients with diabetes to periodontal disease.
Older adults have high rates of autoimmunity, when the individual’s own antibodies (autoantibodies) act as foreign antigens, attacking serosal surfaces, joints, eyes, and/or skin at the molecular, cellular, or tissue levels. Examples of autoimmune conditions seen more commonly in elders include pernicious anemia, thyroiditis, bullous pemphigoid, rheumatoid arthritis, and temporal arteritis. Some autoimmune conditions may present with aphthous type oral ulcerations and chronic jaw osteomyelitis. Chronic inflammation can generate an immunosuppressive microenvironment that provides further advantages for tumor formation and progression.
In an effort to eliminate acute and low-grade inflammation from the oral cavity, more vigilance and at times more aggressive treatment may be needed against periodontal conditions and caries. A customized approach for each individual should be based on the individual’s presentation of disease and a thorough assessment of his or her unique strengths and capabilities, as well as considerations of the family’s and/or caregiver’s roles, capacities, and interests. Box 1 displays elements of preventive plans for older adults.
Risk assessment for diseases of hard and soft tissues
Evaluation of physical plaque removal skills
Recommendation of manual and/or electronic devices
Possible caregiver assistance in managing daily oral hygiene
Demonstrated ongoing improved daily oral hygiene
Preventing caries and periodontal disease through chemopreventive agents
Selection of in office and at home adjuncts to mechanical cleaning
Replacement of saliva with appropriate substitutes
Development of regular professional recare plan
Typically, ongoing surveillance of intraoral infection should not ignore systemic signs such as fever. When challenged, however, the aging immune system is not always capable of demonstrating fever. Therefore, assessing and monitoring body temperature changes over multiple visits and comparing readings with that person’s baseline value may provide better information on any temperature elevations than a standardized normal temperature target.
Nutrition and malnutrition
Malnutrition describes a state of nutrition whereby a deficiency of nutrients results in changes to the body (shape, size, and composition), and its functional capabilities that is, clinically obvious. Early detection of malnutrition is difficult owing to multiple, conflicting criteria and, as a result, it frequently becomes advanced before being noticed. When finally diagnosed, malnutrition is still not always properly addressed, even though it has been clearly shown to be a factor associated with morbidity, mortality, and cost of care. ,
The prevalence of malnutrition in older adults is complex and multidirectional, stemming from different operating domains (eg, oral, psychosocial, physical, lifestyle, health, and eating habits), all of which influence each other. These domains vary from person to person and over time and are cohort anchored, being higher in older adults with multimorbidities especially when health deterioration, lack of physical activity and dependency in the activities of daily living (ADLs) are present. The relationships between factors correlated with malnutrition in older adults can be seen in a graphic at the following website ( nutritionandaging.org/wp-content/uploads/2017/01/DetermineNutritionChecklist.pdf ) that can be easily used by the dental practitioner and staff to instruct patients and family members or care givers and can also be used as a self-help home reminder.
Malnutrition also seems to have multiple effects on the oral tissues and subsequent oral disease. Conditions such as recurrent aphthous stomatitis, atrophic glossitis, or a painful, burning tongue characterized by inflammation and defoliation are possibly caused by nutritional deficiencies such as vitamin B and iron. A lack of protein and deficiencies of certain micronutrients such as vitamins, zinc, and iron can influence the amount and the composition of the saliva, limiting its protective properties.
The systematic review performed by O’Keeffe and colleagues provides moderate evidence that chewing difficulties, mouth pain, gum issues, multimorbidity, visual and hearing impairments, smoking status, alcohol consumption, physical activity levels, and even complaints about taste of food and specific nutrient intakes were not correlated with malnutrition; there is low-quality evidence that loss of interest in life, access to Meals on Wheels, and modified texture diets are determinants of malnutrition. Further, the influence of some potential determinants of malnutrition such as dental status, swallowing, cognitive function, depression, residential status, medication intake and/or polypharmacy, constipation, and periodontal disease were conflicting. Additional research in this area is needed because malnutrition is strongly associated with sarcopenia, which may impact periodontal disease, support of complete dentures, and frailty.
The Determine Your Nutritional Health is an easy and brief (10 question) survey to which the patient can be introduced and can self-administer in just a few minutes in the dental office. Its answers provide important insights into the patient’s nutritional behaviors as well as several other areas including the impact of the dentition on eating, weight loss, and the patient’s ability to manage multiple ADLs and instrumental ADLs as related to food preparation and consumption. Patients with difficulties highlighted by this survey can then be referred to the local Area Agencies on Aging offices for help in finding state and local resources that can include nutritional information programs as well as food distribution programs. The survey is available at the previously mentioned website:
Unintentional weight loss (10 lbs. in the past year) occurs in 15% to 20% of people older than 65 years of age and is related to increased risk for morbidity and mortality. There is a higher prevalence of this finding in nursing home residents (50%–60%) as compared with community-dwelling elders (27%).
Unintentional weight loss can be a result of decreased intake (the most common explanation in older adults), increased nutrient loss owing to malabsorption, and excess systemic demands resulting from malignancies. Weight loss may also be associated with depression and dementia. Community-dwelling elders may become unable physically and/or cognitively to grocery shop and cook meals or have limited income or access to nutritional foods. Certain medications can cause anorexia. Conditions that impact the respiratory system such as emphysema, make the coordination of breathing and eating activities difficult; Sjogren’s syndrome may decrease the selection of a variety of foods owing to a self-recognition of an inadequate amount of saliva to prepare the bolus of food for swallowing.
Besides oral conditions influencing weight loss, it is also possible that the anorexia of aging may be at work. A decrease in lean body mass, bone mass, and the basal metabolic rate, coupled with a decrease in the senses of taste and smell and altered gastric signals leading to early satiation combine to bring about this effect. The resulting weight loss is very gradual, a little less than one-half of a pound a year.
Oral health has often been described as one of the factors affecting weight in older adults; aspects such as teeth and denture-related issues, oral pain, oral lesions, dry mouth, and periodontal problems can prevent masticatory function, resulting in an imbalanced diet. Oral health often deteriorates during aging, sometimes owing to morbidities or behaviors, for example, poor oral hygiene or smoking. Dry mouth can negatively impact the taste and texture perception of food. Recently, Kiesswetter and colleagues found that community-dwelling elders self-reported estimation of their own oral status significantly correlated to their clinical body weight. Perhaps this one question could be easily integrated into clinical practice to identify older people at risk of weight loss and to initiate oral interventions.
Given the high prevalence of the anorexia of aging, it is likely that some family members concerned that weight loss could be related to a lack of/or ill-fitting dentures or other dentition related problems will bring their aging relatives who have lost weight to the dental office. A thorough examination, especially of the fit of prostheses, is needed because there may or may not be any deficiencies for the dentist to repair.
When weight loss does occur, it often results in the loosening of dentures, friction sores on the edentulous ridges, dissatisfaction with the fit, and ultimately decreases in life satisfaction. Unintentional weight loss caught early and investigated may allow early diagnosis and reversal of morbid trends. Consider adding height and weight assessments to the regular collection of vital signs, especially for your older adult patients to track insidious weight loss.
Muscle weakness can be the result of the combined effects of sarcopenia, osteopenia, and organopenia. Whereas sarcopenia is the loss of muscle mass as an outcome of normal aging, osteopenia describes the depletion over time of bone mass owing to an imbalance between resorptive and formative processes, with organopenia being the loss in appendicular muscle and bone mass with increasing age. All of these conditions contribute to the increasing prevalence of disability in older adults.
In sarcopenia, the rate of muscle loss ranges between 1% and 2% per year at ages greater than 50 years, with 25% of people less than 70 years of age and 40% of those greater than 80 years of age being sarcopenic. When existing alone, sarcopenia is likely a minor and modifiable risk factor for health outcomes, but not when found in conjunction with declining muscle strength and physical functioning. A sedentary lifestyle and bed rest often result in microcirculatory disturbances in the skeletal muscle, atrophy, protein loss, and so on, resulting in decreases in muscle mass, structure, and strength.
Muscle weakness results from declinations of both neurologic and muscular dynamics, or dynapenia that recognizes the force-generating capacity of the skeletal muscles as a component. Muscle weakness also contributes to dysfunctions of locomotion and balance in the elderly with vitamin D deficiency playing a significant role; more than one-half of all women treated for osteoporosis in the United States and Europe are estimated to have low levels as a result of decreased dietary intake, diminished sunlight exposure, decreased skin thickness, impaired intestinal absorption, and impaired hydroxylation in the liver and kidneys. Fig. 2 presents an overview of the interplay between poor oral status, malnutrition, and sarcopenia.
Vitamin D is important to calcium absorption in the gastrointestinal tract with adequate levels decreasing the risk of fractures. Even when taken uncoupled with calcium, vitamin D shows improvement in osteoporosis. Some researchers have found a relationship between vitamin D, and periodontal disease. Although not a causal factor, Megson and colleagues suggest that decreased bone mineral density and periodontitis have shared risk factors.
Overall, the gradual loss of muscle strength below a certain threshold results in functional impairment, the need for assistance in the performance of ADLs, and increased risk of falling and nonvertebral fractures. It is possible that grip strength and upper arm strength are associated, especially in the poststroke patient. Paresis can result in 1-sided loss of muscle strength of the upper extremity on the contralateral stroke side, decreasing the ability to use the arm and hand fully. If the affected side was dominant, the patient can have a great deal of difficulty retraining the nondominant hand for usual ADL tasks.
Because oral home care is highly dependent on upper arm strength and hand grip to use various dental cleaning devices, the preservation of muscle strength in older adults is critical and rehabilitation of upper limb capabilities in a stroke patient is of paramount importance. Patients can be shown procedural modifications in how to use implements that minimize the impact of their losses. For example, sitting at a table and propping one’s elbows on the tabletop as oral hygiene devices are being used helps to override the muscular weaknesses of the upper extremity. The tabletop can also serve as an anchor to the pivot points (elbows) when both hands are needed to jointly guide the toothbrush or flossing device to the mouth from the tabletop-elbow prop. Using this strategy can also offset the negative factor of weight of a battery powered toothbrush.
In dental practice, we typically do not have dynamometers to measured grip strength, but a general impression of such strength can be judged in the dental practice by introducing oneself to the patient, accompanied by a handshake. If a patient is unable to grasp another’s hand and hold it, or does so only weakly, some thoughtful planning is needed in developing a doable oral health care home program. Handle diameters sized at 30 to 40 mm are the most comfortable, in contrast with that of 10 to 15 mm (the size of manual toothbrushes). Therefore, enlargement of the toothbrush handle or recommending a battery-operated toothbrush should be considered.
Here is a good example of why an interdisciplinary team approach is so important to older adults: the poststroke dental patient is likely to continue to benefit from the guidance of a physical therapist in regaining strength and function even after the immediate poststroke rehabilitation period, as well as an occupational therapist who can assess and recommend methods and instrumentation to aid in meeting ADLs, even when diminished physical functioning remains.
Encouraging the patient at every dental appointment to continue performing the exercises learned during poststroke rehabilitation or in any number of exercise classes for healthy aging seniors needs to be a part of a lifelong daily routine. Exercise is important to the continuous training, retraining, restoring, and maintaining of muscular strength to perform activities throughout the lifespan, including those for managing one’s own oral hygiene.
Falls are the leading cause of fatal and nonfatal injuries in people aged 65 or older. Even in community-dwelling older adults, the fall rate can be as high as 75% over a 3-month interval, with 45% of the falls resulting in injuries, 25% of which are likely to be bone fracture. Although an intrinsic lack of bone integrity owing to structural skeletal losses (eg, osteoporosis) plays a role in the skeletal damage sustained in a fall, bone malignancies, and treatments with radiation and hormonal therapy among other medications may also be contributors. Nonskeletal influences of falls include fatigue, peripheral neuropathy, dizziness, and sensory disorders of vision and balance. Those who have fallen previously are more likely to fall again as the underlying cause is often not corrected or correctable. Trauma to the face as a result of falls may include abrasions, ecchymosis, and fractures. Similar intraoral findings include lacerations of the tongue and lips, and possible damage to the dentition. Because cuts and bruises are one of the signs of elder abuse, when such damage is observed, a full history of injuries should be taken by the provider to distinguish whether a report should be filed with the proper governmental agency. Box 2 presents some approaches to preventing decline and improving muscle strength and coordination.
Mediterranean diet, anti-inflammatory diet (include fatty fish, more vegetables and fruits), increased carotenoid intake, soy.
Promote mobility, walking, resistance training, yoga, tai chi, comprehensive fall prevention programs.
Fish oil, vitamin D, whey protein, soy protein, and soy isoflavones, amino acid supplementation; anti-inflammatory herbs like curcumin, if general inflammation is present or suspected; the role of vitamin E is not clear.
Androgens and testosterone
Only if deficiency state is present after careful assessment of risk; not recommended for routine use.
When elder abuse is suspected and it is unknown if the state or local government has an Elder Abuse Hotline, login to the State Resources Section of the National Center on Elder Abuse website at eldercare.acl.gov/Public/Resources/LearnMoreAbout/Elder_Rights.aspx#Abuse and use the resources and instructions to fulfill your duties as mandated reporters of elder abuse.
With the falls rate in older adults increasing, the Centers for Disease Control and Prevention through its STEADI initiative has recommended that all health care providers participate in helping to stem the tide. A suite of information including videos and other educational material is available on the STEADI website www.cdc.gov/steadi/about.html . Dental practitioners can help identify individuals at risk by asking 3 simple screening questions and referring for further assessment any older adults who say yes to any of the questions ( Box 3 ).